Pennsylvania Code
Title 28 - HEALTH AND SAFETY
Part VI - Health Care Cost Containment Council
Chapter 912 - DATA REPORTING REQUIREMENTS
Subchapter D - OTHER REQUIREMENTS
Appendix A

Universal Citation: 28 PA Code ยง A
Current through Register Vol. 54, No. 44, November 2, 2024

Pennsylvania

Uniform Claims

and

Billing Form

Reporting Manual

HC-87-101 Volume A-Inpatient Data Reporting

Pennsylvania Health Care Cost

Containment Council

Harrisburg Transportation Center

Suite 208

4th and Chestnut Streets

Harrisburg, Pennsylvania 17101

(717) 232-6787

Purpose

The purpose of this manual is to provide data sources with the technical specifications necessary for data collection and data submissions to the Council. According to Act 89, the collection of health data by the Council will be used to facilitate the continuing provision of quality, cost-effective health services throughout the Commonwealth by providing data and information to the purchasers and consumers of health care on both cost and quality of health care services.

Volume A pertains to data submission formats for hospitals and ambulatory service facilities. The Council will collect the raw data from the various data sources, using some key matching data elements, merge the data to provide records per hospitalization or major ambulatory service visit.

Table of Contents

Index

Hospital and Ambulatory Service Facility Reporting Manual

Header Record Manual

Trailer Record Manual

Hospital and Ambulatory Service Facility Tape Format

Appendices

Index by Data Element Name

Data Element Name Field # UB-92 Form Locater
Admission Date56
Admission Hour 40 18
Admission-Type of 26 19
Admission-Source of 27 20
Admitting Diagnosis 36 76
Certification/SSN/ Health Insurance Claim Number29a-c 60
Discharge Date 6 6
Discharge Hour 41 21
Diagnosis Related Group (DRG) 24 2h
E-Code 37 77
Employer Name 32a-c 65
Employment Status 34a-c 64
Estimated Amount Due 14g 55
Federal Tax ID 39 5
HCPCS/Rates 13a-w6 44
Hispanic/Latino Origin or Descent 35a 2i
Non-Covered Charges 13a-w5 48
Patient Discharge Status 20 22
Patient Date of Birth2 14
Patient Control Number 23 3
Patient-Uniform Identification 1 2a
Patient Race 35b 2j
Patient Relationship to Insured 28a-c 59
Patient Sex 3 15
Patient Zip Code 4 13
Payor Group Number 19 62
Payor Identification 14b 50
Physician Identification-Attending 11 82
Physician Identification-Operating 12 83
Physician Identification-Referring 38 82
Principal Diagnosis 7a 67
Principal Procedure Code and Date 8a, 8b 80
Prior Payments-Payor and Patient 14f 54
Procedure Coding Method Used 25 79
Provider Quality 21a 2d
Provider Service Effectiveness 21b 2e
Revenue Code 13a-w2 42
Reserve Field 21e HC4
Secondary Diagnosis 7b-i 68-75
Secondary Procedure Code and Date 9 81
Service Date 13a-w7 45
Total Charges 13a-w4 47
Type of Bill 22 4
Uniform Identifier of Health Care Facility 10 2b
Uniform Identifier of Primary Payor 17 2c
Units of Service 13a-w3 46
Unusual Occurrence-Nosocomial Infection 21c 2f
Unusual Occurrence-Readmission21d 29

Index by Field Number

Data Element Name Field # UB-92 Form Locater
Patient-Uniform Identification 1 2a
Patient Date of Birth 2 14
Patient Sex 3 15
Patient Zip Code 4 13
Admission Date 5 6
Discharge Date 6 6
Principal Diagnosis 7a 67
Secondary Diagnosis 7b-i 68-75
Principal Procedure Code and Date8a, 8b 80
Secondary Procedure Code and Date 9 81
Uniform Identifier of Health Care Facility 10 2b
Physician Identification-Attending 11 82
Physician Identification-Operating 12 83
Revenue Code 13a-w2 42
Units of Service 13a-w3 46
Total Charges 13a-w4 47
Non-Covered Charges 13a-w548
HCPCS/Rates 13a-w6 44
Service Date13a-w7 45
Payor Identification 14b 50
Prior Payments-Payor and Patient14f 54
Estimated Amount Due 14g 55
Uniform Identifier of Primary Payor17 2c
Payor Group Number 19 62
Patient Discharge Status 20 22
Provider Quality 21a 2d
Provider Service Effectiveness 21b 2e
Unusual Occurrence-Nosocomial Infection 21c 2f
Unusual Occurrence-Readmission 21d 29
Reserve Field21e
Type of Bill 22 4
Patient Control Number 23 3
Diagnosis Related Group (DRG) 24 2h
Procedure Coding Method Used 25 79
Admission-Type of 26 19
Admission-Source of 27 20
Patient Relationship to Insured 28a-c 59
Certification/SSN/Health Insurance Claim Number29a-c 60
Employer Name 32a-c 65
Employment Status 34a-c 64
Hispanic/Latino Origin or Descent 35a 2i
Patient Race 35b 2j
Admitting Diagnosis 36 76
E-Code 37 77
Physician Identification-Referring38 82
Federal Tax ID 39 5
Admission Hour40 18
Discharge Hour 41 21

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